?GG????? ?G??F????? ????S????

1
?GG????? ?G??F????? ????S????

• ?as??e??? ?. ?ast???d?µ??
• ?e????????
• ?p?µe??t?? ?
• ?e?????????? ???????? ??.G.?.?

2
?a????µ?s? ???e?a??? ???efa????? ?pe?s?d???

• ?.?S???????
• ?a??d??? ?s?a?µ??? ?pe?s?d?a (Transient Ischemic
  Attacks-TIAs)
• A?ast????µe? ?s?a?µ???? ?e?????????? ??ata?a???
  (Riversible Ischemic Neurologic Deficit-RIND))
• ???efa???? ?µf?a?µa e? e?e???e?-Stroke in
  evolution
• ????????µ??? e??efa???? ?µf?a?t?

3
?a????µ?s? ???e?a??? ???efa????? ?pe?s?d???

• ???efa???? ??µ???a??a
• ?pa?a???e?d?? a?µ???a??a
• ??d??????a?? ??µ???a??a
• ???? a?e???sµat?? / a?t????f?eß?d??? d?sp?as?a?
  (AVM)
• T??µß?s? e??efa????? f?eß??
• ??a????sµ?? (dissection) e?d???????? ?a? a??e???
  t?a?????

4
?a??f?s??????a ?s?a?µ???? ???
5
?a??f?s??????a ?s?a?µ???? ???
6
???efa???? a?µat??? ??? ?a?

• ???a e??efa????? a?µat???? ???? (??as??? ???s?)
• ?a?????? ????a?µ?a (benign oligemia) gt17-40 mL
  /100 g per minute
• Penumbra10-17 mL/100 g a?? min
• ?????a? eµf???t?? (core)lt10 mL/100 g a?? min
• ???sfat? µeta-a????s? ?de??e p?? ta ???a
  e??efa????? a?µat???? ???? (CBF thresholds)
  eµf????a? µe???? ete?????e?a ?a? ??µa????ta?
• Penumbra14.1- 35.0 mL/100 g a?? min
• ?????a? eµf???t?? (core) 4.8-8.4 mL/100 g a??
  min

Bandera et al., Stroke. 2006371334-1339
7
??as???? ???sµ?? t?? penumbra (mismatch model)
Kidwell et al., Stroke. 2003342729-2735
8
S??????? d?????s? t?? d?af??et???? ?atast?se??
?s?a?µ???? eµf???t??
Kidwell et al., Stroke. 2003342729-2735
9
?pe?????s? t?? Penumbra
10
?????????????S? (DWI-PWI mismatch- ape?????s?
penumbra
11
?a?????te? ???d???? ??a ???

• ?????a
• ???????µe?? ???/???
• ?p??tas?
• Sa??a??d?? ??aß?t??
• ??p??sµa
• ???p??? µa?µa????
• ?a??sa???a
• ?pe???p?da?µ?a
• ?ata????s? a??????
• St???s? ?a??t?d?? (s?µpt?µat??? ? µ?)

12
?a?????te? ???d???? ??a ???

• ???? a?t?s????pt????
• ????e????a?µ?a
• ??t?f?sf???d??? s??d??µ? (??? ? ap?? s???pa???
  APL)
• ?????µ?t?s? t?? a??t???? t????
• ????µ??? ?µ???ste???
• ???ptt?s? µ?t??e?d??? (gt50)
• ?µ???a??a
• ?????t?? ß?t???e??? p????(patent foramen ovale)

13
??? (???)

• ?? ?a??d??? ?s?a?µ??? ?pe?s?d?? e??a? ??a ß?a??
  epe?s?d?? ?e?????????? d?ata?a??? s??epe?a
  est?a??? e??efa????? ? aµf?ß??st??e?d????
  ?s?a?µ?a? µe ??????? s?µpt?µata ?a? t?p???
  d????e?a µ????te?? t?? µ?a? ??a? (5min-24 ??e?)
  ????? ??de??? ????? eµf???t??

TIA Working Group, NEJM 20023471713-16
AHA definition of TIA A transient episode of
neurological dysfunction caused by focal brain,
spinal cord, or retinal ischemia, without acute
infarction.
Stroke. 2009402276-2293
14
Frequency of DWI Abnormality in Patients
WithTransient Neurological Episodes of Different
Durations Pooled Data From 10 MRI Studies
Enrolling 818 Patients
Defining TIA with a 24-hour maximum duration has
the potential to delay the initiation of
effective stroke therapies (Class I, Level of
Evidence C). A 24-hour limit for transiently
symptomatic cerebral ischemic is arbitrary and
not reflective of the typical duration of these
events.
15
??????s? ??? (???)
?????? ???????? ??????? ????????
S?µpt?µata ?st?a??, t?p???, ?µ?sfa????? ?a??d??? aµa???s?, s????s?, d?ata?a?? s??e?d?s??, µ? ?µ?sfa?????
?????e?a gt 2 min lt 2 min
?e?e?ta?? ??? lt 24 h gt 24 h
???t? ??? lt 24 h gt 6 µ??e?
U/S Triplex a??e??? t?a????? St???s? gt70-99 , ????d?? p???a (?µ?p?e??a) St???s? lt 50 ??? ß??ß?
?a?????te? ???d???? St???s? ?a??t?d?? ?????? ???d???? ?a?-d?a?? eµß???????? p??? ?? s?????? st???s? ?a??t?d?? ? ?a?d???e??? ?µß???
16
???/??? ?a??t?d???? s?st?µat??S?µe??????a ap? t?
?µ?sfa????

• Amaurosis Fugax (?a??d??? aµa???s?) ?µ?p?e??a
• ??ata?a??? ?????-p?a??a?-???s?a? (ep???at?t???
  ?µ?sfa????)
• ?a??d??? ete??p?e??? ?µ?p??es? ? ade???t?ta
• ?a??d??? ete??p?e??? ?µ??pa?s??s?a
• ?????? ?µ?a????s? (?? ?µ?sfa????)
• ?te??p?e??? ?µ???µ? ?µ?a????a
• ??ata?a?? st? s????? st??f? t?? ß??µµat??

17
???/??? sp??d???ßas???? s?st?µat??

• ????, s????s?, d?ata?a?? ep?p?d?? s??e?d?s?? ?
  t?s? ??a ??p???µ?a p?? s??d???eta? µe ??a ?
  pe??ss?te?a ap? ta pa?a??t?
• ??p??p?a
• ??s?atap?s?a
• ??sa????a
• ??????? (µe ? ????? d?ata?a?? a????)
• ????? ad??aµ?a t?? d?? ??t? ? ?a? t?? d?? ???
  ?????
• ??s??t???? d?ata?a??? t?? d?? ??t? ? ?a? t?? d??
  ??? ?????
• ?a?e??efa??d??? ata??a
• ???sß??? t?? ???se?? aµf?te??p?e??a

18
ABCD score
19
RED FLAGS ??a s?µe??????a ap? t? st??e???

• ??ata?a?? ????t???t?ta?-a?s??t???t?ta? ?a? sta 4
  ???a
• ??ap??????? ?f?a?µ?p????a (INO)
• ??sta?µ?? ata??a d?sa????a d?s?atap?s?a
  ?µ?p??es? ?µ??pa?s??s?a
• ???es? ??a??a??? ?e???? ?µ?p?e??a ?a? p??sß???
  ????t???t?ta?/a?s??t???t?ta? ete??p?e??a (??ast?
  s??d??µ?)

20
RIND Riversible Ischemic Neurologic Deficit

• ?a?atetaµ??a e??efa???? epe?s?d?a p?? ?d????? se
  p???? ?as?. ???ad? a? ta s?µpt?µata d?a????? ??a
  p??? ap? 24 ??e? a??? e??a? p????? a?ast????µa

21
??µ?t?s? e??ef????
22
S?µe??????a ap? t? a??ste?? ?µ?sfa????

• ?p?f?a?? µe????? a?t?????? ? f??????? ???d??
• ?fas?a
• R ?µ?p??es?
• R ?µ??pa?s??s?a
• R ?????? ?µ?a????s?
• R ?µ???µ? ?µ?a????a
• ??ata?a?? st? de??a s????? st??f? t?? ß??µµat??

23
S?µe??????a ap? t? de??? ?µ?sfa????

• ?p?f?a?? µe????? a?t?????? ? f??????? ???d??
• L ?µ?p??es?
• L ?µ??pa?s??s?a
• L ?????? ?µ?a????s?
• L ?µ???µ? ?µ?a????a
• ??ata?a?? st? a??ste?? s????? st??f? t??
  ß??µµat??

24
???ST?? ?G??F????? ???????

• ?µ?p??es? ete??p?e??a (p?d?)
• ?pa?s??s?a ete??p?e??a
• ????te?a ?????
• ??ta?a??ast??? s??????? (grasp), pa?at???a
  (gegenhalten)
• ?ß????a, ap??e?a, ap?a??a ß?d?s??
• ??sp?a??a , alien hand (R ACA)
• ??af?????? ????t??? afas?a

25
???ST?? ?????????S ???????

• ?µ?a????a ete??p?e??a (sectoranopia)
• ?µ??pa?s??s?a (p??? ??s?? µe??? st? ????)
• ?µ?p??es?
• ?µ?ata??a

26
???ST?? ?G??F????? ???????

• ?µ?a????a ?µ???µ? ete??p?e??a
• ??e??a (? a??af?a)
• ????s?a ???µ?t??, ?pt??? , p??s?pa???s?a (R),
  pe??ß?????t?? (R), ??s?a???s?a
• ?ata??µast??? ? d?af????? a?s??t??? afas?a
• ?pt???? ?e?da?s??se??, pa??????a, µetaµ??f???a
• ????µat???a , a???et???a, f?????? t?f??s?
  (Anton), s??d??µ? Balint

27
S?µe??????a ap? t? st??e???

• ??ata?a?? ????t???t?ta?-a?s??t???t?ta? ?a? sta 4
  ???a
• ??ast? s??d??µ? (?µ?p?e??a st? p??s?p? ?a?
  ete??p?e??a st? s?µa)
• ??ata?a?? s??????? st??f?? ß??µat?? (INO)
• ??sta?µ??
• ?ta??a
• ??sa????a
• ??sfa??a

28
??S?G??F????? ??F?????

• ???sß??? ?????? ????t???? (???) ?µ?p?e??a
• ???sß??? ???et?? s?????? ????se??
• ?te??p?e??? ata??a (Claude)
• ?te??p?e??? ?µ?p??es? (Weber)
• ?te??p?e??? ata??a ?µ?p??es? ?a? t??µ??(Benedict)

29
??F????? ??S G?F???S

• ???sß??? V, VI, VII
• ???sß??? ??????t?a? s??????? ????s?? (d?ap???????
  ?f?a?µ?p????a)
• Lacunar s??d??µa (?a??pt?a)
• ?te??p?e??? ?µ??pa?s??s?a, ?µ?p??es?, ?µ?ata??a

30
?s?a?µ??? ?µf?a?ta p??µ??????????? p??µ?????
s??d??µ?(Wallenberg)
31
?????? p??µ????? s??d??µ?(Wallenberg)
32
?p?f?a?? ßas???? a?t???a?

• ?a?ap??es?, ?pe??ef?e??a, Babinski () ?µf?
• ??sfa??a, d?sa????a, p??es? p??s?p????
• ??p??p?a, ??sta?µ??, pa??se?? ?f?a?µ?????t????
  ?e????, d?ap??????? ?f?a?µp????a (INO)
• ??ata?a?? ep?p?d?? s??e?d?s?? (p??sß??? d??t??t??
  s??µat?sµ??, RAS)
• Locked-in syndrome

33
??t???????? ta????µ?s?
34
LACUNAR INFARCTS

• ?p?f?a?? µ????? d?at?t?a????s?? a??e??? p??
  e??????ta? ap? µe?a??te?a se ?daf?? a?t???a???
  ?pe?t?se?? µe ? ????? S?
• S???? se s??p???? pe??????
• ?? ?µ?? s?µß??? st? st??e??? ? t?? ?s? ???a
  p???a???? ?a?a?t???st??? s??d??µa

35
S??d??µa ?e??t?p??d?? (lacunar) eµf???t??

• ???S??S Is?a?µ??? ?µf?a?ta µe?????? 0.5mm-1.5cm
• ????? ???????st?? 20 ????? pe????afe?
• ?µ???? ????t??? ?µ?p??es?
• Aµ??e?? a?s??t???? d?ata?a???
• Oµ?p?e??? ata???? ?µ?p??es?
• Dysarthria-clumsy hand
• Sensory-motor stoke

36
??t?a ?a?d??eµß?????? ???

• ?????a ???p??? µa?µa???? (???) ?a? ?a????sµ??? ??
  (PAF)
• ??? ?µf?a?µa ????a?d??? (???) (?d??? µe s???d???
  pa?????te? ???d???? ?p?? s?µf???t??? ?a?d?a??
  a?ep???e?a, ???, t????µat??? ???µß?,
  a?e???sµat??? d??tas? ?????a?, s?ßa??? ßa?µ??
  d?s?e?t?????a t?? a??ste??? ?????a?)
• ???a????? p??s?et???? ?a?d?a??? ßa?ß?de?
• ???p??s?et???? ?a?d?a??? ßa?ß?de?
• ???? 3 p??t??? µ??e?
• Se s??d?asµ? µe ???, ???µß? a??ste??? ???p??,
  s?st?µat??? eµß???
• St???s? µ?t??e?d??? ßa?ß?da? ?e?µat????
  a?t??????a?
• S??d??µ? ??s???t?? f?eß???µß??
• ???p???? pte????sµ??
• ??atat??? µ???a?d????e?a
• T??µß?? a??ste??? ?????a? ? ???p?? (?t???)
• ?????t??? ? ?p?????t??? tµ?µa t????µat??
  a??ste??? ?????a?

37
?µß????? ???

• 20-25 ???? t?? ?s?a?µ???? epe?s?d???
• ?p?t?µ? e?sß??? se s??d?asµ? µe ap??e?a
  s??e?d?s?? ? ?a? ep???pt??? ???s?
• ?a?t?????? ? d?ad????? eµf???s? p???ap???
  e??efa????? epe?s?d???
• ?a???s?a s?st?µat???? eµß?????? epe?s?d???
• 30-40 t?? as?e??? ???, p??sfat? ?? ? ?a?d?a??
  a?ep???e?a
• S???? a?µ???a???? µetat??p? eµf???t?? (20)
• ???d?? t?? µ?s?? e??efa???? p?? ?d????? se afas?a
  p??sß?????ta? s????te?a, e?? ap? t?
  sp??d???ßas???, ?? ?p?s??e? e??efa????? a?t???e?.

38
BORDER ZONE INFARCTS

• A. Watershed infarcts (between 2 arterial
  territories with collateral network)
• B. End- artery-border-zone-infarct (between 2
  arterial territories without collaterals)
• ???????T?G?????
• ?p?f?a?? ? µe????? ßa?µ?? st???s? ?a??t?da?
• S?st?µat??? ?p?tas?
• ??µat???????? ??s??, eµß??? ap? ????ste????

39
?????s???µe?a?? f???t?da ?st?????

• ?????? ??a???? s?µpt?µ?t??
• ??ast????t?ta as?e???? t?? ??a t?? ???
• S???d? s?µpt?µata ep???pt??? ???s?, ?µet??,
  ?efa?a???a, d?ata?a?? ep?p?d?? s??e?d?s??
• ?t?µ??? a?aµ??st??? as???e?e?, e??e???se??
• ?????? fa?µa?e?t??? a????
• ???e???e? se f??µa?a, ???s? pa????µ?? ??s???
• ?a?????te? ???d???? ??a ???

40
?????s???µe?a?? f???t?da???te? ß???e?e?

• ABCs (?e?a?????, ??ap???, Sf??µ??, ??t???a??
  ??es?)
• ???stas?a a????a (???????)
• ???d?t?s? µe IV N/S 0.9 (f?s????????? ????)
• O2 -???µet??a
• ??e???? t?µ?? ????????
• ??t?µet?p?s? ?????? ? ?aµ???? a?t???a??? p?es??

41
???efa???? a?t?????µ?s?
42
???efa???? a?t?????µ?s? se ?pe?tas?????
43
???s?se??

• CBFCPP/ CVR
• CBF cerebral blood flow, CPP cerebral perfusion
  pressure, CVR cerebrovascular resistance
• CPP MAP-ICP
• MAP mean arterial pressure, ICP intracranial
  pressure
• MAPSBP (2 x DBP)/3

44
????? ?e?ape?a?

• Te?ape?t??? pa??µßas? e?? ? ??s? ??? 130 mmHg ?
  S?st????? ?? ? 220 mmHg
• Se as?e?e?? ?p???f???? ??a ???µß???s? ? st????
  e??a? S?? lt185mmHg ?a? ??? lt110 mmHg
• Se as?e?e?? µe stefa??a?a ??s? ? ?a?d?a??
  a?ep???e?a p?? e?tat??? p??sp??e?a µe??s?? ??

45
???µ?s? a?t???a??? p?es?? ep????? a?t??pe?tas????

• St???? e????? BP 150/85-95 mm Hg ??a as?e?e??
  ??e? ?pe?t?se?? ?a? 160-170/90-100 mm Hg ??a
  as?e?e?? µe ?st????? ?p??tas??
• ?p???µ?t? µ?s? ?? 80-130 mm Hg
• ? ?at? 10 e?? µ?s? ??gt 130 mm Hg ? s?st?????
  ??gt220 mm Hg (ap?f??? a??e???e???? ??d?µat??)
• F??µa?a e?????? a-??? (e?a?ap????), a?ta????st??
  Ca (?d??? st??? ??????µ????? µe Isol. Syst.H),
  ARB, ?aßeta????

46
Low Blood Pressure Linked to Recurrent Stroke
SBP Recurrent Stroke Rates (95 CI) () Adjusted HR For 1st Stroke Recurrence (95 CI) Adjusted HR for Stroke,MI, or Vascular Death (95 CI)
Very low-normal 8.0 (6.8 - 9.2) 1.29 (1.07 - 1.56) 1.31 (1.13 - 1.52)
Low-normal 7.2 (6.4 - 8.0) 1.10 (0.95 - 1.28) 1.16 (1.03 - 1.31)
High-normal 6.8 (6.1 - 7.4) Reference Reference
High 8.7 (7.9 - 9.5) 1.23 (1.07 - 1.41) 1.24 (1.11 - 1.39)
Very high 14.1 (13.0 - 15.2) 2.08 (1.83 - 2.37) 1.94 (1.74 - 2.16)

• Patients were categorized by their mean SBP over
  follow-up as very low-normal (lt120 mm Hg),
  low-normal (120 to lt130 mm Hg), high-normal (130
  to lt140 mm Hg), high (140 to lt150 mm Hg), and
  very high (gt150 mm Hg).

JAMA. 20113062137-2144.
There was no indication that careful
blood-pressure lowering treatment with the
angiotensin-receptor blocker candesartan is
beneficial in patients with acute stroke and
raised blood pressure. Analysis of functional
outcome suggested a higher risk of poor outcome
in the candesartan group.
SCAST trial, Lancet 2011 377 74150
47
? ?pe?????a?µ?a st? ?s?a?µ??? ???

• ????????? ? a?ae??ß?a ???????s? ? ? ?a?a?t???? ?
  ?a?a?t??? ????s?
• ? pe?a?t??? d??spas? t?? a?µat?e??efa?????
  f?a?µ??
• ? eµp?d??e? t?? epa?a?µ?t?s?
• ? a??e???e??? ??d?µa
• ?ep?de???s? ?s?a?µ?a?

48
S??t?µ? f?s??? ?a? ad?? ?e????????? e??tas?

• ??e???? ??a ?pa??? t?a?µat??
• ?e????????? e??tas? p??sa?µ?sµ??? ??a ???
• 1. ???fasµ??
• 2. ?pa?????? ap??? p??tas??
• 3. ????µas?a Barré
• 4. S?µe?? ?abinski
• 5. ?µ?a????a (st?? ape???)

49
???F??????G?OS?

• ?eta???t??? pa????s? t?? Todd
• ?pe?tas??? e??efa??p??e?a
• ?p?p?e?µ??? ?µ???a??a
• ??????/µetaß????? d?ata?a??(e??efa??p??e?a)
• ???????e??efa??t??
• ???efa???? ap?st?µa
• ?a??d??? sfa????? aµ??s?a
• ?p?/?p?s?????d?? a?µ?t?µa

50
CT ??? ?ata??µ?? ACAMCA
51
??? ?ata??µ?? mPICA
DWI
FLAIR
52
??e?e???s?

• ??????? t?µ???af?a ( C ep? ???µß?s??
  e??efa????? f?eß??)
• MRI (MRA se ?p????a a?e???sµat??, AVM, ???µß?s??
  e??efa????? f?eß??, d?a????sµ??)
• ?riplex a??e??? t?a?????
• U/S ?a?d???
• Holter HKGt??
• ??e???? ????stat???? ?p?tas??

53
Te?ape?a

• ?p?st????t???
• F?s???e?ape?a

54
Te?ape?a-?????????????????

• ?S?????? ?13 ???d???? ??a ???/???/a??e?a??
  ???at?
• ???????????????? (???p?d?????? 75mg/d, ? 22
  ER d?p???daµ??? ASA 20025mg bid, t??f???s???
  600mg/d)
• se as?e?e?? ?????? ???d???? ??a ??? ??? (gt15-20
  a?? ?t??)
• se as?e?e?? p?? de? µp????? ?a ??ß??? asp?????
• se as?e?e?? p?? pa?? t?? a???? µe asp?????
  pa???s?????? ???s

Lancet Neurol 2010 9 27384
55
??t?p??t??? Te?ape?a

• Stroke in evolution
• ?µß????? epe?s?d?a
• ?s?a?µ??? sp??d???ßas???? s?st?µat???
• Crescento TIAs (a??a??µe??? s????t?ta? ?a?
  ??tas??)
• ?e????? d????e?a? ?????
• ?a??t?d??? st???s? gt90?
• ?atast?se?? ?pe?p??t???t?ta?
• T??µß?s? f?eß?? e??ef????
• ??a????st??? a?e???sµata

56
Zafeiris Spyros, Mastorodemos Vasileios, Mavridis
Michalis, Tzagournissakis Minas, Spilioti Martha,
Plaitakis AndreasDepartment of Neurology,
University Hospital of Heraklion, Crete, Greece
PO4.119

• Acute Anticoagulation with Intravenous
  Un-Fractionated Heparin Reduces Early Recurrences
  in Cardio-Embolic Stroke

Neurology, 74 (9) Suppl. 2) A347 2010.
57
Results

• Early recurrence (within the first 10 days)
  occurred in
• 1.2 (3/246) of patients treated with
  un-fractionated IV heparin
• 1.4 (1/68) of patients treated with continued
  oral anticoagulation
• 4.8 (4/82) of patients treated with
  anti-platelets (x2lt 3.8, plt0.01).
• Symptomatic hemorrhagic conversion occurred in
• 3.2 (8/246) of patients treated with heparin
• 3.6 (3/82) (x2 gt3.84, p0.9) treated with
  anti-platelet agents.
• 0 (0/68) treated with continued oral
  anticoagulation

58
Te?ape?a CE stroke
Recurrence SCH
IST (lt7-14d)a Placebo (n775) SC UFH (n1557) APS (n837) 2.5 2.8 2.3 0.3 2.1 0.6
TOAST (7d) Placebo (n123) IV danaparoid (n143) 1.6 0 0.95b 2.9b
TAIST (10d)a LMWH (n256) APS (n112) 1.6 1.8 2.7 0
HAEST (14d) LMWH (n224) APS (n225) 8.5 7.5 2.7 1.8
CAST (28d)c Placebo (n715) APS (n696) 5 5 2.8 2.4
Recurrence SCH
Cretan (11d) IV UFH (n240) APS (n78) 1.2 5.1 3.2 3.6
Chamorro (14d) IV UFH (n231) 2.2 3.4
Camerlingo (90d)a Placebo (n85) IV UFH (n94) NR NR 2.4 10.6
CESG (14d)a Placebo (n21) IV UFH (n24) 10 0 10 0
RAPID (7d) d IV UFH (n32) APS (n35) 0 8.6 6.3 8.6
aAdapted from the meta-analysis of Paciaroni et
al, Stroke 200738423-430. bThese numbers
correspond to patients allocated to IV danaparoid
(n638) and placebo (n628). cAdapted from Hart R
et al , Stroke. 2002332722-2727. d37 of those
allocated to ASA and 56 of those allocated to
UFH had CES.
59
CONCLUSIONS

• Acute anticoagulation of CES using
  un-fractionated IV heparin was associated with a
  low risk for early recurrence (1.2 N246)
  without an increase in symptomatic hemorrhagic
  conversion.
• In our patients treated with anti-platelets, the
  rate of early recurrence (4.8 N82) was
  comparable to that observed in previous large
  controlled CES clinical trials.
• Data of this retrospective analysis support a
  randomized trial of this treatment approach.

60
Te?ape?a as?e??? µe CE ???
?a?a?t???st??? as?e??? Te?ape?a
?????a lt 6?, ??? ?a?d?a?? ??s?? (µ??? ???) ?sp????? 325mg
?????a lt6?, µe ?a?d?a?? ??s?? a??? ????? pa?????te? ???d???? ?sp????? 325mg
?????a 6?, µe ?a?d?a?? ??s?? a??? ????? pa?????te? ???d???? ?sp????? 325mg
?????a 60 µe S/? ? Stefa??a?a ??s? Sintrom (INR 2.0-3.0)
?????a 75, ?d??? ???a??e? µe ?.?, ???sµa e????s?? a??ste??? ?????a? lt0.35, ??t???a?? ?p??tas? ?a? T??e?t?????s? Sintrom (INR 2.0 ) Sintrom (INR 2.0-3.0)
?a?ß?d?p??e?a ?e?µat???? a?t??????a? (st???s? µ?t??e?d???) Sintrom (INR 2.5-3.5)
???s?et???? ßa?ß?de? Sintrom (INR 2.5-3.5)
?st????? ???µß?eµß?????? epe?s?d??? Sintrom (INR 2.5-3.5)
?pa??? ???µß?? st?? ?? ???p? Sintrom (INR 2.5-3.5)
61
????F????? T??????????? T??????? (e?de??e??)

• ?p?ßeßa??µ??? d?????s? ?s?a?µ???? ??? µe
  ?e????????? ???e?µµa (p.?. NIHSS score gt6)
• ??a??? ?e?ape?a? se d??st?µa lt3 ???? ap? t??
  ??a??? s?µpt?µ?t??
• ? ?e????????? s?µe??????a de? ?a p??pe? ?a
  ap??a??stata? a?t?µata ?a? ?a e??a? e??ss?? ?a?
  µeµ???µ???. Se as?e?e?? µe ßa??? ?e?????????
  e????a (p.?. NIHSS score gt22) ?a p??pe? ?a
  e?at?µ??e?eta? ? efa?µ??? t?? ?e?ape?a?.
• ? as?e??? ?a? ? ???????e?a ????? e??µe???e?
  epa???? ??a ta p??a?? ?f??? ?a? pa?e????e?e? ?a?
  ????? s?µf???se? st?? efa?µ??? t?? ?e?ape?a?

62
????F????? T??????????? T??????? (???t???a
ap???e?sµ??)

• ?pa??? ? ?st????? p??????µe??? e?d?e??efa?????
  a?µ???a??a?
• ?st????? p??sfat?? (e?t?? t?? 3 te?e?ta??? µ????)
  ???, ??a???e??efa????? ????s?? (???), ?????
  eµf???µat?? µ???a?d??? (???).
• ?st????? pe???a?d?t?da?, e?d??a?d?t?da?,
  s?pt???? eµß????, IBD, e???µ?s????-?a?????a?
• ?st????? a?µ???a??a? ap? t? pept??? ? t?
  ????p???t??? t?? te?e?ta?e? 21 ?µ??e?.
• ?st????? µe?????? ?e?????????? ep?µßas?? t??
  te?e?ta?e? 14 ?µ??e?.
• ?st????? pa?a???t?s?? a?t???a? se pe????? p?? de?
  ep?d??eta? efa?µ??? p?es?? t?? te?e?ta?e? 7
  ?µ??e?.
• ????s? a?t???a??? p?es?? (???a S?st????? ?? lt185
  mm Hg ?a? ? d?ast????? ??lt110 mm Hg, 3 µet??se??
  a?? 10 min)
• S?µe?a e?e????? a?µ???a??a? ? ????? t?a?µat?sµ??
  (p.?. ?at??µat??) st? f?s??? e??tas?.
• ???? a?t?p??t???? a????? ap? t?? st?µat?? ? e??
  ?aµß??e? t? INR1.5
• ??? ??e? ??ße? a?t?p??t??? a???? µe e?d?f?ß?a ?
  ?p?d???a ?pa???? t?? te?e?ta?e? 48 ??e?, t? aPTT
  p??pe? ?a e??a? e?t?? t?? f?s????????? ?????.
• ? a???µ?? t?? a?µ?peta???? p??pe? ?a e??a? gt100
  000 mm3.
• ? t?µ? ???????? ???? ?a e??a? gt50 mg/dL (2.7
  mmol/L) ?a? lt 400 mg/dL
• ??d???s? t?? ??? µe ???s? ? ?a? µeta???t???
  ?e????????? s?µe??????a.
• ? CT e??ef???? de???e? p?????ß?de? ?µf?a?t? ?a?
  t? ?µf?a?t? ?ata?aµß??e? ?p?p???? ape?????s? gt1/3
  t?? pe?????? ?ata??µ?? t??

63
???????????? T???????S?????????S

• ?s?e?e?? µe ??a??? s?µpt?µ?t?? 3-6 ??e?
• ??? ste?????? µe ??a??? e?t?? 6 ???? (??µa lt 6
  ??e?, tet?ap????alt 6 hours, p?????sa ????t???
  ad??aµ?a, ???µß?s?/ap?f?a?? ßas???? ? sp??d??????
  ?µf?)
• Se as?e?e?? µe ?µf?a?t? t?? µ?s?? e??efa????? ?a?
  ??a??? e?t?? 3 ???? p?? e?te ?p???e?
  a??e????af??? ep?ßeßa??s? ap?f?a??? e?te ep?
  ap?t???a? t?? e?d?f??ß?a? ???µß???s??

64
?p?p????? ???

• ?e??????????
• ?d????fa???
• ????µ??? e?d??????a p?es? (??d?µa, ?????easµ??)
• ?p???pt???? ???se??
• ??µ???a???? µetat??p?
• ??e?µ??????????
• ??s??f?s?
• ??
• ??e?µ???a
• ?a?d?a??e?a???
• ?s?a?µ?a µ???a?d???
• ?????µ?e?
• ?a?d?a?? a?ep???e?a
• ??FT (DVT)
• ???e?
• ?ata???se??

65
?G??F????? ???????G??

• ??t???a?? ?p??tas?
• ?µ???e?d?s?
• ??µat???????? d?ata?a???
• ??µ???a???? µetat??p? eµf???t??
• S?µpa??t???µ?µ?t???? pa?????te?
• ??a?µa
• ?????
• ??t????f?eß?d?? d?sp?as?a
• S??a???de? a?µa??e??µa
• ??e???sµata

66
??t?p?s? a?µ???a??a?
67
CT-e?d?pa?e???µat??? a?µ???a??a µe ta?e?a ep??tas?
68
??t?µet?p?s?

• ?p??d?µat??? a???? (de?aµe?a???? 24mg/H ?a?
  ?p?d?p?as?asµ?? ???e 2?)
• ??t?-? a???? (??? p??f??a?t????, e?a??es?
  ??ß?de?? a?µ???a??e?)
• ???µ?s? a?t???a??? p?es??
• ?pa???e??ta? ??t??p??ss???, ?d?a?a????,
  ??fed?p???
• ??????st?µ?a (a?t?µet?p?s? ?d???efa??a?)
• ??t?µet?p?s? a???µ???? e?d??????a? ?p??tas??

69
The CreteBoston Study
Clinical outcomes-not in OAC
Zaganas et al, Stroke. 2011423640-3642
70
??de??e?? ?e?????????? a?t?µet?p?s??

• ?a?e??efa??d??? a?µ???a??a gt3 cm, µe ep?de???s?
  ?e????????? ? s?µp?es? ste?????? ?/?a?
  ?d???efa??a ???? ap?f?a??? t?? ??????? (Class I,
  Level of Evidence B).
• ?e ??ß?d? ???µß? se ap?stas? e?t?? 1 cm ap? t??
  ep?f??e?a (Class IIb, Level of Evidence B)
• ?p?de???s? t?? ep?p?d?? s??e?d?s?? (ap? GCS
  ßa?µ?????a µeta?? 12 ?a? 9 se lt8)
• Ste?e?ta?t??? ????s? ????????s?? st?? ?????t?ta
  t?? ???µß?? e?t?? 72 h µe?a??te??? ???d????
  epa?a?µ???a??a?, aß?ßa?a ???s?µ?t?ta (Class IIb,
  Level of Evidence B)

Broderick et al., Guidelines for Management of
Spontaneous ICH in Adults. Stroke
2007382001-2023
71
?????? ?e?????????? ep?µßas??

• ?e? ??e? ap?de???e? p?? ? ?pe?epe????sa
  ??a???t?µ? ße?t???e? t? ?e?t??????? ap?t??esµa ?
  e?att??e? t? ???s?µ?t?ta e?? s???de?eta? ap?
  a???µ??? ???d??? epa?a?µ???a??a? (Class IIb,
  Level of Evidence B).
• ? ?a??ste??µ??? afa??es? t?? a?µat?µat?? µe
  ??a???t?µ? p??a??tata de? ?fe?e?. ?e? s???st?ta?
  se as?e?e?? se ??µa µe e? t? ß??e? a?µ???a??a
  ?a??? s??et??ese se ?e???te?? ?e?t???????
  ap?t??esµa (Class III, Level of Evidence A)

Broderick et al., Guidelines for Management of
Spontaneous ICH in Adults. Stroke
2007382001-2023
72
??te?de??e?? ?e?????????? ep?µßas??

• ? afa??es? ?pe?s????d?a? ICH µe ??as???
  ??a???t?µ? e?t?? 96 ???? ap? t? s?µß?? (Class
  III, Level of Evidence A)
• ????? a?µat?µata lt25 ml
• A?µat?µata se st??e??? ?a? ßas??? ?a????a
• GCSlt6

Broderick et al., Guidelines for Management of
Spontaneous ICH in Adults. Stroke
2007382001-2023
73
F?eß??? ???µß?s?-???d?a?es???? ?a?????te?

• ?a????? ?e?p??sµata
• ?pe?p??t???t?ta
• ??t?s????pt???
• ???e?a ? ???s?
• ?f?d?t?s?
• DIC (???)
• ????e????a?µ?a
• ??t????sa

74
F?eß??? ???µß?s?-???d?a?es???? ?a?????te?

• Genetic prothrombotic conditions
• Antithrombin deficiency
• Protein C and protein S deficiency
• Factor V Leiden mutation
• Prothrombin mutation (A20210G)
• Homocysteinemia (mutations in
• methylenetetrahydrofolate reductase)
• Acquired prothrombotic states
• Nephrotic syndrome
• Antiphospholipid antibodies
• Homocysteinemia
• Pregnancy-Puerperium
• Infections (Otitis, mastoiditis,sinusitis,
• meningitis, systemic infectious disease)
• Inflammatory disease
• Systemic lupus erythematosus
• Wegeners granulomatosis

• Hematologic conditions
• Polycythemia, primary and secondary
• Thrombocythemia
• Leukemia
• Anemia, including paroxysmal nocturnal
• hemoglobinuria
• Drugs
• Oral contraceptives
• Asparaginase
• Mechanical causes, trauma
• Head injury
• Injury to sinuses or jugular vein, jugular
• catheterization
• Neurosurgical procedures
• Lumbar puncture
• Miscellaneous

75
??t?p?s? ?a? s????t?ta
Stam J. N Engl J Med 20053521791-8.
76
??????? e????a

• ?efa?a???a 81
• ??d?µa ????? 51
• ?st?a?? e??e?µµata 38
• ???se?? E 42
• ??ata?a?? ep?p?d?? 30
• s??e?d?s??

77
T??µß?s? e??efa????? f?eß??
78
T??µß?s? e??efa????? f?eß??
79
??d?af????sa pe??pt?s? (1)
80
??d?af????sa pe??pt?s? (1)
St? f??
St? s??t?d?
81
??d?af????sa pe??pt?s? (1)
82
??d?af????sa pe??pt?s? (1)

• ???G?OS?
• ????O??S??S ???S????S ?SO ???O????S

83
??a????sµ?? ?s? ?a??t?da?

• ??t?µat?? (st? 20 d?ata?a?? t?? ????a?????, st?
  15 ???µ??d? d?sp?as?a)
• ??a?µat????
• Precipitating events ?pe???tas? ? st??f? t??
  a????a, ?e???p???te?
• ??????? t???da ?µ?p?e??? ????? (?efa???,
  a????a, p??s?p??), partial Horner,?p??ta?
  e??efa???? ? aµf?ß??st??e?d??? ?s?a?µ?a (st?
  50-90, p???????ta? ???) , pa??se?? ??a??a???
  ?e???? st? 12
• ??t?p??t??? a???? ??a 3-6 µ??e?

84
MRA
85
CADASILCerebral Autosomal Dominant Arteriopathy
with Subcortical Infarcts

• Strokes (subcortical and lacunar)
• TIAs
• Dementia (multi-infarct)
• Pseudobulbar Palsy

• Migraine Headaches
• Depression
• Urinary Incontinence

86
MRI
87
MELASMitochondrial myopathy, Encephalopathy,
Lactic acidosis, Seizures

• Encephalopthy
• Myopathy
• Strokes
• Hearing Loss
• Seizures

• Migraine Headaches
• Myoclonus
• Ataxia
• Cardiomyopathy

88
???a??st? ??a t?? p??s??? sa?
89
?p??tas? µet? ?s?a?µ??? ???AHA guidelines (2003)
90
?p?????sµ?? ????? a?µat?µat??

• ????? a?µat?µat?? AxBxC/2 (?/3 ??a ICH µet?
  ???? a?t?p??t????),
• ?p??
• A µe??st? ??????t?a d??µet??? a?µ???a??a? st??
  CT scan
• B µe??st? ???et? d??µet??? a?µ???a??a? st?? CT
  scan
• C a???µ?? t?µ?? p?? eµfa???eta? ? a?µ???a??a ep?
  t? p???? t?µ??

Broderick et al., Stroke 199324987993 Huttner
et al., Stroke 200637 404-408